Evolution of Minimally Invasive Approaches to the Sella and Parasellar Region

Abstract

Introduction Given advancements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, and anatomical understanding, the endonasal endoscopic approach has rapidly evolved into a widely utilized technique for removal of sellar and parasellar tumors. Although pituitary adenomas and Rathke cleft cysts constitute the majority of lesions removed via this route, craniopharyngiomas, clival chordomas, parasellar meningiomas, and other lesions are increasingly removed using this approach. Paralleling the evolution of the endonasal route to the parasellar region, the supraorbital eyebrow craniotomy has also been increasingly used as an alternative minimally invasive approach to reach this skull base region. Similar to the endonasal route, the supraorbital route has been greatly facilitated by advances in endoscopy, along with development of more refined, low-profile instrumentation and surgical navigation technology. Objectives This review, encompassing both transcranial and transsphenoidal routes, will recount the high points and advances that have made minimally invasive approaches to the sellar region possible, the evolution of these approaches, and their relative indications and technical nuances. Data Synthesis The literature is reviewed regarding the evolution of surgical approaches to the sellar region beginning with the earliest attempts and emphasizing technological advances, which have allowed the evolution of the modern technique. The surgical techniques for both endoscopic transsphenoidal and supraorbital approaches are described in detail. The relative indications for each approach are highlighted using case illustrations. Conclusions Although tremendous advances have been made in transitioning toward minimally invasive transcranial and transsphenoidal approaches to the sella, further work remains to be done. Together, the endonasal endoscopic and the supraorbital endoscope-assisted approaches are complementary minimally invasive routes to the parasellar region.

Endoscopic vs. Microscopic Resection of Sellar Lesions—A Matched Analysis of Clinical and Socioeconomic Outcomes

“…The endoscopic view is noted to provide a wider degree of freedom and improved visual access to the sella, although limitations related to lens cleaning and “sword fighting” with instruments have been acknowledged ( 4 ). The microscopic approach provides three-dimensional visualization and surgeon familiarity with the operating microscope ( 5 ).…”

Expanded Endoscopic Endonasal Transtuberculum / Transplanum Approach to the Suprasellar Area: A Stepwise Approach

“…13 On the other hand, the EEETT approach is limited by the following: laterally by the carotid arteries, difficult hemostasis, the tumor's vascular involvement, 2-D endoscope visualization, and pre-fixed optic chiasm. Therefore, in the context of the minimally invasive approach, 14 the EEETT development brought forth a safe surgical option to maximize midline lesions resection and minimizing the drawbacks of the open approaches. Thereby, it is possible to find an earlier tumor devascularization, a minimal optic apparatus manipulation, and a direct view of the anatomical structures presented in suprasellar infrachiasmatic area such as the optic nerves, the superior hypophyseal arteries, the pituitary stalk, and retrochiasmatic region.…”

Endoscopic endonasal surgery for anterior skull base meningiomas

“…The era of endoscopic transsphenoidal surgery began in the late 1990s, bringing with it improvement of illumination, image quality, viewing angle and dexterity over previous microscopic approaches. Since then, endonasal techniques have expanded into both sagittal and coronal planes, including the anterior skull base [1][2][3][4][5][6][7][8] . This region endoscopically is defined posteriorly by the tuberculum sellae, anteriorly by the posterior table of the frontal sinus, and laterally by the junction of the lamina papyracea and the fovea ethmoidalis.…”